Fracture of the Frontal Sinus in Children Sam C. Weber, MD, Arnold M. Cohn, MD
\s=b\ Two juvenile patients, ages 5 and 8, had traumatic fractures of the frontal sinus that included involvement of the nasal-frontal ducts and posterior tables. Principles of management are discussed and the techniques for the operative procedures described. While rare in occurrence in children, it is felt that traumatic involvement of the nasal-frontal ducts or posterior tables of the frontal sinus requires an osteoplastic flap\p=m-\fat obliteration of the frontal sinus cavity in order to preclude subsequent mucocele development or mucosal ingrowth into the anterior fossa.
(Arch Otolaryngol 103:241-244, 1977)
Fractures dren
are
of facial bones in chil-
relatively
rare as com-
with facial fractures occurring in the adult, and as a result, have received somewhat less attention in the literature than similar trauma occurring in older patients. However, an excellent review of some of these problems has recently been presented.1.2 Etiological factors resulting in facial bone fractures in children center around accidental falls, play-
pared
ground injuries, and automobile acci-
dents. Contributing to the lesser incidence of injury to the pediatric facial bones are the differences of lifestyles in individuals of this age group and the soft resilient bony structures of children that are seemingly able to sustain considerable trauma without fracture, as compared to the more rigid bones of the adult. But just as important, is the possibility of missAccepted
for publication Nov 30, 1976. From the Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, Houston. Reprint requests to Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, TX 77030 (Dr
Cohn).
ing
a
fracture in the
group because of the
pediatric age difficulty in
diagnosis. Just as the child may be unwieldy in the physician's office, the radiologist finds similar difficulty in obtaining satisfactory roentgenograms because of poor patient cooperation and the frequent need of seda-
tion. Furthermore, the appearance of naturally occurring suture lines further complicates roentgenographic
diagnosis.
Trauma to the frontal sinus in chilcourse, is extremely rare because of its incomplete development until the approximate age of 16 years, at which time it usually reaches adult size. The frontal sinuses begin to invade the frontal bone approximately at the end of the second year of life, and at about 4 to 6 years of age, lie 1\m=1/2\ to 5 mm above the level of the nasion. The frontal sinuses in children may be present on roentgenograms between 5 and 6 years of age, but usually do not become clinically important until the age of 10 to 12 years.3 Nasal injuries in children, just as in adults, if severe enough may involve the nasal frontal complex, with possible mucocele development, and the posterior table of the frontal sinus which could result in a CSF rhinorrhea or mucosal ingrowth into the anterior fossae. We have recently had occasion to treat two pediatric cases wherein the frontal sinus was involved secondary to trauma. Its infrequent occurrence in this age group prompts us to report their management when it was felt
dren, of
operative intervention
was
required.
REPORT OF CASES Case 1.\p=m-\Thefirst patient was a 5-year\x=req-\ old girl who was admitted to the hospital after being struck by an automobile. She
due to a probable cerebral concussion, but was able to obey simple commands and respond to pain. Multiple injuries were apparent, which included facial lacerations and obvious trauma to the head. Pertinent physical examination revealed bilateral periorbital swelling and subconjunctival hemorrhage with normal mobility of the extraoccular muscles. Additionally, there was swelling of the nasal dorsum. A patent airway was present with no respiratory distress. Obvious malocclusion was present. Subsequent to immediate cleansing and suture of the facial lacerations under local anesthetic, the patient was admitted to the intensive care unit for observation. Roentgenograms demonstrated free air in the soft tissues of the frontal area, but no evidence of pneumocephalus. Though the frontal sinuses appeared cloudy, a comminuted fracture involving both the anterior and posterior walls could be demonstrated with extension into the ethmoidal sinuses as well (Fig 1). Additionally, a fracture of the sphenoid sinus was suspected along with a fracture of the left infraorbital rim and the lateral wall of the left orbit. There was also a fracture of the body of the mandible and a second fracture just to the left of the midline of the symphysis of the mandible. Nine days after her admission, the child was taken to the operating room where a tracheostomy was performed and mandibular reduction obtained, using a closed technique with intermaxillary fixation. The left malar complex was explored as was the left orbital rim and was reduced satisfactorily. No blowout component was noted. Because of the time element involved, it was elected to stage her surgical procedures and return a week later to explore the frontal sinus. This was accomplished via a coronal flap and an osteoplastic frontal sinusotomy. A depressed fracture of the anterior table of the frontal sinus on the left was noted with extension superiorly into the frontal bone. The left nasal frontal duct was completely obliterated by fractured segments that
appeared lethargic
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Fig 1.—Fractures
are
tables; also involved
demonstrated through frontal sinus involving anterior and posterior the ethmoid and supraorbital and infraorbital rims (patient 1).
are
nent physical findings included dilated pupils, periorbital edema and ecchymosis, and a left-sided hemotympanum. Skull
x-ray films demonstrated a left parietoocin association with nasal and frontal sinus fractures that included both the anterior and posterior tables (Fig 5). Subsequent to carotid arteriography, the patient had immediate epidural hema¬ toma evacuation subsequent to which she improved neurologically and seven days later had a nasal fracture and frontal sinus fracture rehabilitated by an ostéoplastie flap-fat obliteration procedure. Her post¬ operative course was benign and cosmetic result excellent.
cipital fracture
Fig
2.—Fractures with comminution
involving
extended also into the ethmoidal complex (Fig 2). Subsequent to raising of the ostéo¬ plastie flap, a fracture of the posterior table was noted on the right (Fig 3). Dura was exposed, but intact, and no CSF leakage was noted. The roof of the left orbit was severely comminuted, and free segments of bone were debrided (Fig 4). The mucosal lining of the sinus was hyperplastic. This mucosa was removed after which the bony walls of the sinus were burred using an air drill. Temporalis fascia was taken and placed into both nasal
left nasal frontal duct
(patient 1).
frontal ducts and fat previously taken from a left-lower quadrant horizontal incision was used to obliterate the remaining area of the sinus. Periosteum was closed with 3-0 chromic suture and the incision closed and drained. One year postoperative, the patient remains asymptomatic with no obvious aesthetic complication from the ostéoplas¬ tie flap. Case 2.—The patient was an 8-year-old girl who was admitted in semicoma subse¬ quent to blunt trauma to the head. Perti-
COMMENT The point has already been made that maxillofacial injuries in children are rare as compared to their inci¬ dence in adults. A review of general principles of management of such injuries has recently been made by Bernstein.' Even more rare are inju¬ ries in children wherein frontal si¬ nuses are seldom developed to a clin¬ ical extent and involved in such injury. Such involvement in two cases have prompted this report. Management of traumatic injury to
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/28/2015
et al5
Fig 3.—Fracture
of
posterior table
on
right (patient 1).
report large series of cases wherein the ostéoplastie flap is uti¬ lized and report on their low incidence of complications. Of particular inter¬ est is a low incidence of infection of the fat graft when used in surgery for chronic infection of the frontal sinus, and the viability of the fat that has been demonstrated both experimen¬ tally and clinically, though in varying amounts a portion of the fat graft is replaced by fibrous tissue. Of partic¬ ular importance is the cosmetic result. The result of this procedure is one unattended by extensive facial defor¬ mity that is frequent following other procedures relevant to frontal sinus. Sessions et al,5 however, do report frontal bossing in three of their patients, though even this mild cos¬ metic complication resulted only in patients in whom surgery was per¬ formed for chronic infection. Similar frontal bossing was not noted in patients operated for trauma or osteoma.
Fig 4.—Comminuted fracture;
loose
segments involving roof of left orbit (patient 1).
the frontal sinus in adults has been the subject of several recent reports; however, we may make a particular reference to the reports of Montgom¬ ery4 and also that of Sessions et al,5 wherein use of the ostéoplastie flapfat obliteration procedure for frontal sinus surgery has been extensively tested. This procedure received its initial popularity in the United States with the descriptions of Goodale and Montgomery." Subsequently, Mont¬ gomery and Pierce7 gave support to the rationale for the utilization of fat in achieving complete obliteration of the frontal sinus; however, they addi¬ tionally suggest that removal of the inner cortical lining of this sinus is necessary to successfully achieve fat obliteration, and that simple stripping of the mucous membranes is not suffi¬ cient to achieve success. We will not
enter into the details of the procedure in this report since it follows the same guidelines as indicated by Montgom¬ ery.· There are several advantages to utilizing this technique in surgery of the frontal sinus. First, it is a direct approach that allows complete visual¬ ization of both frontal sinuses as well as examination of the nasal frontal ostia. It also allows management of the posterior table and durai complica¬ tions when present as well as manage¬ ment of supraorbital ethmoidal cells. Furthermore, morbidity of the opera¬ tion is low and requiring little postop¬ erative care. It limits deformity and is cosmetically acceptable. It is also highly effective and reduces the inci¬ dence of subsequent complication by eliminating the nasal frontal ostia. Bosley,8 Montgomery,' and Sessions
The indication for open exploration of the frontal sinus by an ostéoplastie flap subsequent to trauma has gener¬ ally been an obvious depressed frac¬ ture of the anterior table, roentgenographic evidence of involvement of the nasal-frontal duct, and fracture involvement of the posterior table; in the latter instance, it is felt that exploration is necessary and a fat obliteration procedure needed in order to preclude mucosal extension through the fracture line into the anterior fossa. Furthermore, utilization of an ostéoplastie procedure allows direct suture repair of dura were it to be lacerated and associated with a CSF rhinorrhea. It also isolates the dura from the upper respiratory tract by obliteration of the nasal frontal ducts and sinus. It has been our judgment that when nasal-frontal duct involve¬ ment has been demonstrated, such a procedure is needed in order to insure against late development of either mucocele or pyocele. This has been substantiated by the above mentioned reviews. It is of interest that trauma was the most common indication leading to this operation in the series reported by Sessions et als who report only one complication as a result of the procedure and that was a postop-
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/28/2015
5.—Demonstrable parietooccipital fractures with extention into frontal sinus to involve anterior and posterior tables.
Fig
erative infection in a patient with marked comminution of the anterior wall compounded by a contaminated laceration over the involved sinus. Where examination and roentgenographic confirmation demonstrate an intact nasal frontal duct and an intact posterior table, treatment of this area in children should be as conservative as possible and limited perhaps to simple elevation of a depressed frac¬ ture of the anterior table when such a fracture is isolated from the nasalfrontal duct. Bernstein' has emphasized the ne¬ cessity for early but conservative reduction of fractures to the facial
bones in children. This is necessary in order to reduce deformity subsequent to rapid healing in children, but furthermore minimize the surgical effects on growth centers and iatrogenically induced deformity. Because the frontal sinus seldom reaches clin¬ ical significance until approximately age 10, and furthermore, seldom reaches adult size until age 16, the question of management of frontal sinus injury in the younger age group has not been extensively addressed. While we agree entirely with the prin¬ ciples as advanced by Bernstein, the extent of injury demonstrated in these two patients prompted a more
aggressive approach to avoid subse¬ quent mucocele development or exten¬
sion of mucosa into the anterior fossa. Based on the experience in adults, we would anticipate little direct defor¬ mity as the result of the procedure. Time only will allow evaluation of any deformity the result of altering growth patterns from this procedure; however, with preservation of the anterior perichondrium, we anticipate future development of the anterior table in normal contour. It is, nonethe¬ less, still prudent to warn parents about the possibility of subsequent deformity and possible need for later cosmetic revision.
References 1. Bernstein L: Maxillofacial injuries in children. Otolaryngol Clin North Am, 1969, pp 397\x=req-\ 401. 2. Dingman R, Natvig P: Surgery of Facial Fractures. Philadelphia, WB Saunders Co, 1964, pp 311-325. 3. Bernstein L: Pediatric sinus problems. Otolaryngol Clin North Am 4:127-143, 1971. 4. Montgomery WW: Surgery of the frontal
sinuses.
Otolaryngol Clin
North Am 4:97-126,
1971. 5. Sessions
RB, Alford BR, Stratton C, et al: Current concepts of frontal sinus surgery: An appraisal of the osteoplastic flap\p=m-\fatobliteration
operation. Laryngoscope 82:918-930,
1972. 6. Goodale RL, Montgomery WW: Experiences with osteoplastic anterior wall approach to
frontal sinuses. Arch
Otolaryngol 68:271-283,
1958. 7. Montgomery WW, Pierce DL: Anterior osteoplastic fat obliteration for frontal sinus: Clinical experience with animal studies. Trans Am Acad Ophthalmol Otolaryngol 67:46-57, 1963. 8. Bosley WR: Osteoplastic obliteration of the frontal sinuses. Laryngoscope 80:1463-1476, 1970.
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/28/2015
\s=b\ Two juvenile patients, ages 5 and 8, had traumatic fractures of the frontal sinus that included involvement of the nasal-frontal ducts and posterior tables. Principles of management are discussed and the techniques for the operative procedures described. While rare in occurrence in children, it is felt that traumatic involvement of the nasal-frontal ducts or posterior tables of the frontal sinus requires an osteoplastic flap\p=m-\fat obliteration of the frontal sinus cavity in order to preclude subsequent mucocele development or mucosal ingrowth into the anterior fossa.
(Arch Otolaryngol 103:241-244, 1977)
Fractures dren
are
of facial bones in chil-
relatively
rare as com-
with facial fractures occurring in the adult, and as a result, have received somewhat less attention in the literature than similar trauma occurring in older patients. However, an excellent review of some of these problems has recently been presented.1.2 Etiological factors resulting in facial bone fractures in children center around accidental falls, play-
pared
ground injuries, and automobile acci-
dents. Contributing to the lesser incidence of injury to the pediatric facial bones are the differences of lifestyles in individuals of this age group and the soft resilient bony structures of children that are seemingly able to sustain considerable trauma without fracture, as compared to the more rigid bones of the adult. But just as important, is the possibility of missAccepted
for publication Nov 30, 1976. From the Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, Houston. Reprint requests to Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, TX 77030 (Dr
Cohn).
ing
a
fracture in the
group because of the
pediatric age difficulty in
diagnosis. Just as the child may be unwieldy in the physician's office, the radiologist finds similar difficulty in obtaining satisfactory roentgenograms because of poor patient cooperation and the frequent need of seda-
tion. Furthermore, the appearance of naturally occurring suture lines further complicates roentgenographic
diagnosis.
Trauma to the frontal sinus in chilcourse, is extremely rare because of its incomplete development until the approximate age of 16 years, at which time it usually reaches adult size. The frontal sinuses begin to invade the frontal bone approximately at the end of the second year of life, and at about 4 to 6 years of age, lie 1\m=1/2\ to 5 mm above the level of the nasion. The frontal sinuses in children may be present on roentgenograms between 5 and 6 years of age, but usually do not become clinically important until the age of 10 to 12 years.3 Nasal injuries in children, just as in adults, if severe enough may involve the nasal frontal complex, with possible mucocele development, and the posterior table of the frontal sinus which could result in a CSF rhinorrhea or mucosal ingrowth into the anterior fossae. We have recently had occasion to treat two pediatric cases wherein the frontal sinus was involved secondary to trauma. Its infrequent occurrence in this age group prompts us to report their management when it was felt
dren, of
operative intervention
was
required.
REPORT OF CASES Case 1.\p=m-\Thefirst patient was a 5-year\x=req-\ old girl who was admitted to the hospital after being struck by an automobile. She
due to a probable cerebral concussion, but was able to obey simple commands and respond to pain. Multiple injuries were apparent, which included facial lacerations and obvious trauma to the head. Pertinent physical examination revealed bilateral periorbital swelling and subconjunctival hemorrhage with normal mobility of the extraoccular muscles. Additionally, there was swelling of the nasal dorsum. A patent airway was present with no respiratory distress. Obvious malocclusion was present. Subsequent to immediate cleansing and suture of the facial lacerations under local anesthetic, the patient was admitted to the intensive care unit for observation. Roentgenograms demonstrated free air in the soft tissues of the frontal area, but no evidence of pneumocephalus. Though the frontal sinuses appeared cloudy, a comminuted fracture involving both the anterior and posterior walls could be demonstrated with extension into the ethmoidal sinuses as well (Fig 1). Additionally, a fracture of the sphenoid sinus was suspected along with a fracture of the left infraorbital rim and the lateral wall of the left orbit. There was also a fracture of the body of the mandible and a second fracture just to the left of the midline of the symphysis of the mandible. Nine days after her admission, the child was taken to the operating room where a tracheostomy was performed and mandibular reduction obtained, using a closed technique with intermaxillary fixation. The left malar complex was explored as was the left orbital rim and was reduced satisfactorily. No blowout component was noted. Because of the time element involved, it was elected to stage her surgical procedures and return a week later to explore the frontal sinus. This was accomplished via a coronal flap and an osteoplastic frontal sinusotomy. A depressed fracture of the anterior table of the frontal sinus on the left was noted with extension superiorly into the frontal bone. The left nasal frontal duct was completely obliterated by fractured segments that
appeared lethargic
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/28/2015
Fig 1.—Fractures
are
tables; also involved
demonstrated through frontal sinus involving anterior and posterior the ethmoid and supraorbital and infraorbital rims (patient 1).
are
nent physical findings included dilated pupils, periorbital edema and ecchymosis, and a left-sided hemotympanum. Skull
x-ray films demonstrated a left parietoocin association with nasal and frontal sinus fractures that included both the anterior and posterior tables (Fig 5). Subsequent to carotid arteriography, the patient had immediate epidural hema¬ toma evacuation subsequent to which she improved neurologically and seven days later had a nasal fracture and frontal sinus fracture rehabilitated by an ostéoplastie flap-fat obliteration procedure. Her post¬ operative course was benign and cosmetic result excellent.
cipital fracture
Fig
2.—Fractures with comminution
involving
extended also into the ethmoidal complex (Fig 2). Subsequent to raising of the ostéo¬ plastie flap, a fracture of the posterior table was noted on the right (Fig 3). Dura was exposed, but intact, and no CSF leakage was noted. The roof of the left orbit was severely comminuted, and free segments of bone were debrided (Fig 4). The mucosal lining of the sinus was hyperplastic. This mucosa was removed after which the bony walls of the sinus were burred using an air drill. Temporalis fascia was taken and placed into both nasal
left nasal frontal duct
(patient 1).
frontal ducts and fat previously taken from a left-lower quadrant horizontal incision was used to obliterate the remaining area of the sinus. Periosteum was closed with 3-0 chromic suture and the incision closed and drained. One year postoperative, the patient remains asymptomatic with no obvious aesthetic complication from the ostéoplas¬ tie flap. Case 2.—The patient was an 8-year-old girl who was admitted in semicoma subse¬ quent to blunt trauma to the head. Perti-
COMMENT The point has already been made that maxillofacial injuries in children are rare as compared to their inci¬ dence in adults. A review of general principles of management of such injuries has recently been made by Bernstein.' Even more rare are inju¬ ries in children wherein frontal si¬ nuses are seldom developed to a clin¬ ical extent and involved in such injury. Such involvement in two cases have prompted this report. Management of traumatic injury to
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/28/2015
et al5
Fig 3.—Fracture
of
posterior table
on
right (patient 1).
report large series of cases wherein the ostéoplastie flap is uti¬ lized and report on their low incidence of complications. Of particular inter¬ est is a low incidence of infection of the fat graft when used in surgery for chronic infection of the frontal sinus, and the viability of the fat that has been demonstrated both experimen¬ tally and clinically, though in varying amounts a portion of the fat graft is replaced by fibrous tissue. Of partic¬ ular importance is the cosmetic result. The result of this procedure is one unattended by extensive facial defor¬ mity that is frequent following other procedures relevant to frontal sinus. Sessions et al,5 however, do report frontal bossing in three of their patients, though even this mild cos¬ metic complication resulted only in patients in whom surgery was per¬ formed for chronic infection. Similar frontal bossing was not noted in patients operated for trauma or osteoma.
Fig 4.—Comminuted fracture;
loose
segments involving roof of left orbit (patient 1).
the frontal sinus in adults has been the subject of several recent reports; however, we may make a particular reference to the reports of Montgom¬ ery4 and also that of Sessions et al,5 wherein use of the ostéoplastie flapfat obliteration procedure for frontal sinus surgery has been extensively tested. This procedure received its initial popularity in the United States with the descriptions of Goodale and Montgomery." Subsequently, Mont¬ gomery and Pierce7 gave support to the rationale for the utilization of fat in achieving complete obliteration of the frontal sinus; however, they addi¬ tionally suggest that removal of the inner cortical lining of this sinus is necessary to successfully achieve fat obliteration, and that simple stripping of the mucous membranes is not suffi¬ cient to achieve success. We will not
enter into the details of the procedure in this report since it follows the same guidelines as indicated by Montgom¬ ery.· There are several advantages to utilizing this technique in surgery of the frontal sinus. First, it is a direct approach that allows complete visual¬ ization of both frontal sinuses as well as examination of the nasal frontal ostia. It also allows management of the posterior table and durai complica¬ tions when present as well as manage¬ ment of supraorbital ethmoidal cells. Furthermore, morbidity of the opera¬ tion is low and requiring little postop¬ erative care. It limits deformity and is cosmetically acceptable. It is also highly effective and reduces the inci¬ dence of subsequent complication by eliminating the nasal frontal ostia. Bosley,8 Montgomery,' and Sessions
The indication for open exploration of the frontal sinus by an ostéoplastie flap subsequent to trauma has gener¬ ally been an obvious depressed frac¬ ture of the anterior table, roentgenographic evidence of involvement of the nasal-frontal duct, and fracture involvement of the posterior table; in the latter instance, it is felt that exploration is necessary and a fat obliteration procedure needed in order to preclude mucosal extension through the fracture line into the anterior fossa. Furthermore, utilization of an ostéoplastie procedure allows direct suture repair of dura were it to be lacerated and associated with a CSF rhinorrhea. It also isolates the dura from the upper respiratory tract by obliteration of the nasal frontal ducts and sinus. It has been our judgment that when nasal-frontal duct involve¬ ment has been demonstrated, such a procedure is needed in order to insure against late development of either mucocele or pyocele. This has been substantiated by the above mentioned reviews. It is of interest that trauma was the most common indication leading to this operation in the series reported by Sessions et als who report only one complication as a result of the procedure and that was a postop-
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/28/2015
5.—Demonstrable parietooccipital fractures with extention into frontal sinus to involve anterior and posterior tables.
Fig
erative infection in a patient with marked comminution of the anterior wall compounded by a contaminated laceration over the involved sinus. Where examination and roentgenographic confirmation demonstrate an intact nasal frontal duct and an intact posterior table, treatment of this area in children should be as conservative as possible and limited perhaps to simple elevation of a depressed frac¬ ture of the anterior table when such a fracture is isolated from the nasalfrontal duct. Bernstein' has emphasized the ne¬ cessity for early but conservative reduction of fractures to the facial
bones in children. This is necessary in order to reduce deformity subsequent to rapid healing in children, but furthermore minimize the surgical effects on growth centers and iatrogenically induced deformity. Because the frontal sinus seldom reaches clin¬ ical significance until approximately age 10, and furthermore, seldom reaches adult size until age 16, the question of management of frontal sinus injury in the younger age group has not been extensively addressed. While we agree entirely with the prin¬ ciples as advanced by Bernstein, the extent of injury demonstrated in these two patients prompted a more
aggressive approach to avoid subse¬ quent mucocele development or exten¬
sion of mucosa into the anterior fossa. Based on the experience in adults, we would anticipate little direct defor¬ mity as the result of the procedure. Time only will allow evaluation of any deformity the result of altering growth patterns from this procedure; however, with preservation of the anterior perichondrium, we anticipate future development of the anterior table in normal contour. It is, nonethe¬ less, still prudent to warn parents about the possibility of subsequent deformity and possible need for later cosmetic revision.
References 1. Bernstein L: Maxillofacial injuries in children. Otolaryngol Clin North Am, 1969, pp 397\x=req-\ 401. 2. Dingman R, Natvig P: Surgery of Facial Fractures. Philadelphia, WB Saunders Co, 1964, pp 311-325. 3. Bernstein L: Pediatric sinus problems. Otolaryngol Clin North Am 4:127-143, 1971. 4. Montgomery WW: Surgery of the frontal
sinuses.
Otolaryngol Clin
North Am 4:97-126,
1971. 5. Sessions
RB, Alford BR, Stratton C, et al: Current concepts of frontal sinus surgery: An appraisal of the osteoplastic flap\p=m-\fatobliteration
operation. Laryngoscope 82:918-930,
1972. 6. Goodale RL, Montgomery WW: Experiences with osteoplastic anterior wall approach to
frontal sinuses. Arch
Otolaryngol 68:271-283,
1958. 7. Montgomery WW, Pierce DL: Anterior osteoplastic fat obliteration for frontal sinus: Clinical experience with animal studies. Trans Am Acad Ophthalmol Otolaryngol 67:46-57, 1963. 8. Bosley WR: Osteoplastic obliteration of the frontal sinuses. Laryngoscope 80:1463-1476, 1970.
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